Preventing Falls and Harm From Falls in Older People - Australian ...

Preventing Falls and Harm From Falls in Older People Best Practice Guidelines for Australian Community Care 2009

ISBN: 978-0-9806298-3-5 © Commonwealth of Australia 2009 This work is copyright. It may be reproduced in whole or part for study or training purposes subject to the inclusion of an acknowledgment of the source. Reproduction for purposes other than those indicated above requires the written permission of the Australian Commission on Safety and Quality in Health Care (ACSQHC). ACSQHC was established in January 2006 by the Australian health ministers to lead and coordinate improvements in safety and quality in Australian health care. Copies of this document and further information on the work of ACSQHC can be found at http://www.safetyandquality.gov.au or from the Office of the Australian Commission on Safety and Quality in Health Care on telephone: +61 2 9263 3633 or email to: [email protected]. Other resources available from http://www.safetyandquality.gov.au: • Guidebook to Preventing Falls and Harm From Falls in Older People: Best Practice Guidelines for Australian Community Care 2009 • Preventing Falls and Harm From Falls in Older People: Best Practice Guidelines for Australian Hospitals 2009 • Guidebook to Preventing Falls and Harm From Falls in Older People: Best Practice Guidelines for Australian Hospitals 2009 • Preventing Falls and Harm From Falls in Older People: Best Practice Guidelines for Australian Residential Aged Care Facilities 2009 • Guidebook to Preventing Falls and Harm From Falls in Older People: Best Practice Guidelines for Australian Residential Aged Care Facilities 2009 • Implementation Guide for Preventing Falls and Harm From Falls in Older People: Best Practice Guidelines for Australian Hospitals and Residential Aged Care Facilities 2009 • Fact sheets – Falls facts for patients and carers – Falls facts for doctors – Falls facts for nurses – Falls facts for allied health professionals – Falls facts for support staff (cleaners, food service and transport staff) – Falls facts for health managers

Statement from the chief executive

Australians today enjoy a longer life expectancy than previous generations, but for some this is disrupted by falls. As we age, our sure-footedness declines and, at the same time, our bones become increasingly brittle. The comment that ‘he fell and broke his hip’ is heard all too often — in fact, almost one in three older Australians will suffer a fall each year. Such falls can have extremely serious consequences, including significant disability and even death. Falls are one of the largest causes of harm in care. Preventing falls and minimising their harmful effects are critical. During care episodes, older people are usually going through a period of intercurrent illness, with the resultant frailty and the uncertainty that brings. They are at their most vulnerable, often in unfamiliar settings, and accordingly attention has been paid to acquiring evidence about what can be done to minimise the occurrence of falls and their harmful effects, and to use these data in the national Falls Guidelines. These new guidelines consider the evidence and recommend actions in the three main care settings: the community, hospitals and residential aged care facilities. Each of three separate volumes addresses one of these care settings, providing guidance on managing the various risk factors that make older Australians in care vulnerable to falling. The Australian Commission on Safety and Quality in Health Care is charged with leading and coordinating improvements in the safety and quality of health care for all Australians. These new guidelines are an important part of that work. The ongoing commitment of staff in community, hospital and residential aged care settings is critical in falls prevention. I commend these guidelines to you.

Professor Chris Baggoley Chief Executive Australian Commission on Safety and Quality in Health Care August 2009

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Preventing Falls and Harm From Falls in Older People

Contents

Statement from the chief executive

Page

iii

Acronyms and abbreviations

xiii

Preface

xv

Acknowledgments

xvii

Summary of recommendations and good practice points

xix

1

1 Background

3

About the guidelines

3

1.2

Scope of the guidelines

4

1.2.1 Targeting older Australians

4

1.2.2 Specific to the Australian community

4

1.2.3 Relevant to all members of the health care team

4

Terminology

4

1.3.1 Definition of a fall

4

1.3.2 Definition of an injurious fall

4

1.3.3 Definition of assessment and risk assessment

4

1.3.4 Definition of interventions

5

1.3.5 Definition of evidence

5

Development of the guidelines

5

1.4.1 Expert advisory group

5

1.4.2 Review methods

6

1.4.3 Levels of evidence

7

1.5

Consultation

7

1.6

Governance of the review of the Australian Falls Guidelines

8

How to use the guidelines

8

1.3

1.4

1.7

1.7.1 Overview 1.7.2 How the guidelines are presented 2 Falls and falls injuries in Australia 2.1

Incidence of falls

8 10 13 13

2.2 Location of falls

13

2.3 Consequences of falls

14

2.4

15

Cost of falls

2.5 Economic considerations in falls prevention programs

15

2.6 Risk factors for falling

16

3 Involving older people in falls prevention

1.1

Part A Introduction

17

v

Part B Standard falls prevention strategies

19

4 Falls prevention interventions

21

4.1

Background and evidence

22

4.1.1 Use of economic evaluation

22

4.2 Exercise interventions 4.2.1 Targeting falls prevention exercise programs

4.3 Other single interventions

22 23 24

4.3.1 Vitamin D supplementation

24

4.3.2 Medication review and withdrawal

24

4.3.3 Cardiac pacemaker insertion

25

4.3.4 Home safety programs

25

4.3.5 Improving vision

25

4.4 Multiple interventions

26

4.4.1 Economic evaluation

27

4.5 Multifactorial interventions

28

4.5.1 Multifactorial versus single interventions

28

4.5.2 Economic evaluation

29

4.6 Special considerations

29

4.6.1 Cognitive impairment

29

4.6.2 Indigenous and culturally and linguistically diverse groups

29

4.6.3 Rural and remote settings

30

Part C Management strategies for common falls risk factors

33

5 Falls risk screening and assessment

35

5.1


5.2 Principles of care

36 36

5.2.1 Falls risk screening

36

5.2.2 Falls risk assessment

38


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Page

41


41


41


41


6 Balance and mobility limitations 6.1

Page

43


44

6.1.1 Impaired physical functioning increases the risk of falling

44

6.1.2 Exercise as a single intervention

45


45

6.2.2 Providing exercise interventions

47

6.2.3 Including all older people

48


48


48


48


48

6.4 Economic evaluation

49

6.4.1 Tai chi

49

6.4.2 Otago Exercise Programme

49

7 Cognitive impairment 7.1

7.2 7.3

7.4 8.1

51


52

7.1.1 Cognitive impairment associated with increased falls risk

52

Principles of care

52

7.2.1 Assessing cognitive impairment

52

Special considerations

55


55

Economic evaluation

55

8 Continence Background and evidence

45

6.2.1 Assessing balance, mobility and strength

57 58

8.1.1 Incontinence associated with increased falls risk 58 8.1.2 Incontinence and falls intervention 8.2 Principles of care

59 60

8.2.1 Screening continence

60

8.2.2 Strategies for promoting continence

60


61


61


61


61


62

Contents

vii

9 Feet and footwear 9.1

63


64

9.1.1 Footwear associated with increased falls risk

64

9.1.2 Foot problems and increased falls risk

64


66

9.2.1 Assessing feet and footwear

66

9.2.2 Strategies for improving foot condition and footwear

66


9.4

Page

68


68


68


68

Economic evaluation

68

10 Syncope

69

10.1 Background and evidence

70

10.1.1 Vasovagal syncope

70

10.1.2 Orthostatic hypotension (postural hypotension) 70 10.1.3 Carotid sinus hypersensitivity

70

10.1.4 Cardiac arrhythmias

71

10.2 Principles of care 10.2.1 Assessing syncope

71

10.2.2 Treating syncope

71

10.3 Special considerations 10.3.1 Cognitive impairment 10.4 Economic evaluation 11 Dizziness and vertigo 11.1 Background and evidence 11.1.1 Vestibular disorders associated with an increased risk of falling 11.2 Principles of care

72 72 72 73 74 74 74

11.2.1 Assessing vestibular function

74

11.2.2 Choosing interventions to reduce symptoms of dizziness

75


76


76

12 Medications 12.1 Background and evidence 12.1.1 Medication use is associated with increased risk of falls 12.1.2 Medication review 12.2 Principles of care

77 78 78 78 79

12.2.1 Reviewing medications

79

12.2.2 Quality use of medicines

81


81


81


82


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71


82

Page

13 Vision

85

13.1 Background and evidence 13.1.1 Visual functions associated with increased risk of falls 13.2 Principles of care

86 86 86

13.2.1 Screening vision

86

13.2.2 Choosing vision interventions

89 90 90


90


90

13.3.4 People with limited mobility

90


90

14 Environmental considerations

93


94


94

14.2.1 Assessing the older person in their environment

94

14.2.2 Designing multifactorial interventions that include environmental modifications

96 96


96


97

14.3.3 ‘At risk’ people discharged from hospital

97

14.3.4 People with urinary incontinence

97

14.4 Economic evaluation 15 Individual surveillance and observation

97 99


100


100

15.2.1 Assessment

100

15.2.2 Sitter programs

100

15.2.3 Response systems

100


101


101


101





101

Contents

ix

Part D Minimising injuries from falls

103

16 Hip protectors

105


106

16.1.1 Types of hip protectors

106

16.1.2 How hip protectors work

106

16.1.3 Risk associated with hip protectors

106

16.1.4 Adherence to the use of hip protectors

107

16.2 Principles of care 16.2.1 Assessing the use of hip protectors

107 107

16.2.2 Wearing hip protectors

107

16.2.3 Using hip protectors at night

108

16.2.4 Training in hip protector use

108

16.2.5 Cost of hip protectors

108

16.2.6 Review and monitoring

108


109


109


109

16.3.3 Climate

109


109

16.4.1 Hip protector use in the community

109

16.4.2 Hip protector use in mixed settings

110

17 Vitamin D and calcium supplementation 17.1 Background and evidence

111 112

17.1.1 Vitamin D supplementation (with or without calcium)

112

17.1.2 Vitamin D, sunlight and winter

113

17.1.3 Toxicity and dose

113


113


114


114


114

17.4 Economic evaluation 18 Osteoporosis management

114 115


116

18.1.1 Falls and fractures

116

18.1.2 Diagnosing osteoporosis

116

18.1.3 Evidence for medication interventions

116


117

18.2.1 Assessing bone health

117

18.2.2 Providing interventions

117

18.2.3 Review and monitoring

118

18.3 Special considerations 18.3.1 Cognitive impairment 18.4 Economic evaluation

x

Page


118 118 118

Page

Part E Responding to falls

121

19 Post-fall management

123

19.1 Background

124

19.2 Responding to falls

124

19.2.1 Falls incident policies

124

19.2.2 Post-fall follow-up

125

19.4 Reporting and recording falls

126

19.5 Comprehensive assessment after a fall

127

19.6 Loss of confidence after a fall

127

19.7 Falls clinics

127

Appendices

126

19.3 Analysing the fall

129

Appendix 1 Contributors to the guidelines

131

Appendix 2 Falls risk screening and assessment tools

135

Appendix 3 Rowland Universal Dementia Assessment Scale (RUDAS)

141

Appendix 4 Safe shoe checklist

143

Appendix 5 Home Fast

145

Appendix 6 Checklist of issues to consider before using hip protectors

149

Glossary

151

References

153

Tables Table 1.1

National Health and Medical Research Council levels of evidence

7

Table 2.1

Risk factors for falling in the community

16

Table 5.1

Screening tools

37

Table 5.2

Falls risk assessment tools

38

Table 5.3

Specific assessments of risk factors

39

Table 6.1

Tools for assessing balance, gait, mobility and strength

45

Features that should be included in exercise programs

47

Table 7.1

Tools for assessing cognitive status

53

Table 13.1

Characteristics of eye-screening tests

88

Table 18.1

Pharmaceutical Benefits Scheme details for osteoporosis drugs

Table 6.2

118

Figures Figure 1.1

Using the guidelines to prevent falls in Australia

9

Figure 9.1

The theoretical optimal ‘safe’ shoe, and ‘unsafe’ shoe

65

Figure 12.1

Medication risk assessment form

80

Figure 13.1

Normal vision

87

Figure 13.2 Visual changes resulting from cataracts

87

Figure 13.3 Visual changes resulting from glaucoma

87

Figure 13.4 Visual changes resulting from macular degeneration 87

Contents

xi

xii


Acronyms and abbreviations

ACSQHC

Australian Commission on Safety and Quality in Health Care

AMTS

Abbreviated Mental Test Score

BMD

bone mineral density

BPPV

benign paroxysmal positional vertigo

CI

confidence interval

FROP-Com

Falls Risk for Older People (community version) Screening and Assessment tools

GP

general practitioner

HOME FAST

Home Falls and Accidents Screening Tool

ICER

incremental cost-effectiveness ratio

IU

international unit

MMSE

Mini-Mental State Examination

NHMRC

National Health and Medical Research Council

(OH)D

hydroxyvitamin D

PBS

Pharmaceutical Benefits Scheme

ProFaNE

Prevention of Falls Network Europe

QALY

quality-adjusted life year

xiii

xiv


Preface

Falls are a significant cause of harm to older people. The rate, intensity and cost of falls identify them as a national safety and quality issue. The Australian Commission on Safety and Quality in Health Care (ACSQHC) is charged with leading and coordinating improvements in the safety and quality of health care nationally, and has consequently produced these guidelines on preventing falls and harm from falls in older people. Health care services are provided in a range of settings. Therefore, ACSQHC has developed three separate falls prevention guidelines that address the three main care settings: the community, hospitals and residential aged care facilities. Although there are common elements across the three guidelines, some information and recommendations are specific to each setting. Collectively, the guidelines are referred to as the Falls Guidelines. This new document, Preventing Falls and Harm From Falls in Older People: Best Practice Guidelines for Australian Community Care 2009, aims to reduce the number of falls and the harm from falls experienced by older people in the community. The guidelines and support materials are suitable for use by health professionals for individuals and community groups that: • do not have a falls prevention program or plan in place • have recently initiated a falls prevention program or plan • have a successful falls prevention program or plan in place. Older people themselves are at the centre of the guidelines. Their participation, to the full extent of their desire and ability, encourages shared responsibility in health care, promotes quality care and focuses accountability. The guidelines are written to promote independence and rehabilitation. Living in the community involves some risk for many older people. The guidelines do not promote an entirely risk-averse approach to the health care of older people. Some falls are preventable, some are not preventable. However, an excessively custodial and risk-averse approach designed to avoid complaints or litigation from at-risk older people and their carers may infringe on the older person’s autonomy and limit rehabilitation. Whenever possible, these guidelines are based on research evidence and are written to supplement the clinical knowledge, competence and experience applied by health professionals. However, as with all guidelines, and the principles of evidence based practice, their application is intended to be in the context of professional judgment, clinical knowledge, competence and experience of health professionals. The guidelines also acknowledge that the clinical judgment of informed professionals is best practice in the absence of good-quality published evidence. Some flexibility may also therefore be required to adapt these guidelines to specific settings, local circumstances, and to older people’s needs, circumstances and wishes. The following additional materials have been prepared to accompany the guidelines: • Guidebook for Preventing Falls and Harm From Falls in Older People: Australian Community Care 2009. A Short Version of Preventing Falls and Harm From Falls in Older People: Best Practice Guidelines for Australian Community Care 2009 • Falls Guidelines — fact sheets. The two other guidelines for hospitals and residential aged care facilities are the result of a review and rewrite of the first edition of the guidelines, Preventing Falls and Harm from Falls in Older People — Best Practice Guidelines for Australian Hospitals and Residential Aged Care Facilities 2005,1 which were developed by the former Australian Council for Safety and Quality in Health Care.

xv

Key messages of the guidelines • Many falls can be prevented. • Fall and injury prevention needs to be addressed at the point of care and from a multidisciplinary perspective. • Managing many of the risk factors for falls (eg delirium or balance problems) will have wider benefits beyond falls prevention. • Engaging older people themselves is an integral part of preventing falls and minimising harm from falls. • Best practice in fall and injury prevention includes implementing falls prevention strategies, or identifying falls risk and implementing targeted individualised strategies that are resourced adequately, and monitored and reviewed regularly. • Multifactorial interventions (ie a combination of interventions tailored to the individual) are effective for reducing the rate of falls in the community setting. • In the community setting, some single interventions (eg certain exercise programs and home safety programs in high-risk subgroups, and vitamin D with calcium supplementation for older people with low blood levels) can reduce falls and the number of fallers. • The consequences of falls resulting in minor or no injury are often neglected. Factors such as fear of falling and reduced activity level can profoundly affect function and quality of life, and increase the risk of seriously harmful falls. • At a strategic level, there will be a time lag between investment in a falls prevention program and improvements in outcome measures.

xvi


Acknowledgments

The Australian Commission on Safety and Quality in Health Care (ACSQHC) acknowledges the authors, reviewers and editors who undertook the work of reviewing, restructuring and writing the guidelines. ACSQHC acknowledges the significant contribution of the Falls Guidelines Review Expert Advisory Group for their time and expertise in the development of the Falls Guidelines 2009. ACSQHC also acknowledges the contribution of many health professionals who participated in focus groups, and provided comment and other support to the project. In particular, the National Injury Prevention Working Group, a network of jurisdictional policy staff, played a significant role communicating the review to colleagues and providing advice. The guidelines build on earlier work by the former Australian Council for Safety and Quality in Health Care and by Queensland Health. The contributions of the national and international external quality reviewers and the Office of the Australian Commission on Safety and Quality in Health Care are also acknowledged. ACSQHC funded the preparation of these guidelines. Members of the Falls Guidelines Review Expert Advisory Group have no financial conflict of interest in the recommendations in the guidelines. A full list of authors, reviewers and contributors is provided in Appendix 1. ACSQHC gratefully acknowledges the kind permission of St Vincent’s and Mater Health Sydney to reproduce many of the images in the guidelines.

xvii

Falls Guidelines Review Expert Advisory Group Chair Associate Professor Stephen Lord — Principal Research Fellow, Prince of Wales Medical Research Institute, The University of New South Wales

Members Associate Professor Jacqueline Close — Senior Staff Specialist, Prince of Wales Hospital and Clinical School, The University of New South Wales; Honorary Senior Research Fellow, Prince of Wales Medical Research Institute, The University of New South Wales Ms Mandy Harden — CNC Aged Care Education/Community Aged Care Services, Hunter New England Area Health Services, NSW Health Professor Keith Hill — Professor of Allied Health, La Trobe University/Northern Health, Senior Researcher, Preventive and Public Health Division, National Ageing Research Institute Dr Kirsten Howard — Senior Lecturer, Health Economics, School of Public Health, The University of Sydney Ms Lorraine Lovitt — Leader, New South Wales Falls Prevention Program, Clinical Excellence Commission Ms Rozelle Williams — Director of Nursing/Site Manager, Rice Village, Geelong, Victoria, Mercy Health and Aged Care

Project manager Mr Graham Bedford — Policy Team Manager, ACSQHC

External quality reviewers Associate Professor Ngaire Kerse — Associate Professor, General Practice and Primary Health Care, School of Population Health, Faculty of Medical and Health Sciences, The University of Auckland, New Zealand Professor David Oliver — Consultant Physician and Clinical Director, Royal Berkshire Hospital, Reading, United Kingdom; Visiting Professor of Medicine for Older People, School of Community and Health Science, City University, London, United Kingdom Associate Professor Clare Robertson — Research Associate Professor, Department of Medical and Surgical Sciences, Dunedin School of Medicine, University of Otago, New Zealand

Technical writing and editing Ms Meg Heaslop — Biotext Pty Ltd, Brisbane Dr Janet Salisbury — Biotext Pty Ltd, Canberra

xviii


Summary of recommendations and good practice points

This section contains a summary of the guideline’s recommendations and good practice points. These are also presented at the start of each chapter, with accompanying references and explanations.

Part B

Standard falls prevention strategies

Chapter 4

Falls prevention interventions

Recommendations Intervention • Use effective interventions to reduce falls in the community, for example certain exercise programs, assessment followed by multifactorial treatment, home safety interventions in high-risk groups, and academic detailing for general practitioners by a pharmacist. (Level I) 7

Single interventions • Older people should be encouraged to exercise to prevent falls. Certain programs have been shown to be effective and largely focus on balance training. (Level I) 7,40 • Older people with visual impairment primarily related to cataracts should undergo cataract surgery as soon as practicable. (Level II) 41,42 • When conducted as a single intervention, home environment interventions are effective for reducing falls in high-risk older people. (Level I) 43 • For individual older people, gradual and supervised withdrawal of psychoactive medications should be considered to prevent falls. (Level II) 44 • People with severe visual impairment should receive a home safety assessment and modification program specifically designed to prevent falls. (Level II) 45,46 • Use cardiac pacing in older people who live in the community, and who have carotid sinus hypersensitivity and a history of syncope or falls, to reduce the rate of falls. (Level II) 47 • Collaborative review and modification of medication by general practitioners and pharmacists, in conjunction with individual patients, is recommended to prevent falls. (Level II) 48 • Vitamin D and calcium supplementation should be recommended as an intervention strategy to prevent falls in older people who live in the community, particularly if they are not exposed to the minimum recommended levels of sunlight. Benefits from supplementation are most likely to be seen in people who have vitamin D insufficiency (25(OH)D